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Bad Economy Leads Patients to Put Off Surgery, or Rush It

Val Arnold, being examined by Dr. Kenneth Shaheen, chose to have reconstructive surgery before her insurance ran out.Credit
Fabrizio Costantini for The New York Times

As the recession deepens, doctors and hospitals are reporting that hard-pressed patients are deferring elective surgery, like knee replacements and nose jobs, even as others are speeding up non-urgent procedures out of fear that they may soon lose their jobs and health insurance.

With unemployment still rising, there are wide variations by region and type of surgery. That means that highly regarded orthopedic surgeons in Chicago may be as busy as ever, while gastroenterologists in Atlanta are scrambling to fill cancellations.

But even those whose operating rooms are booked months in advance say they anticipate a slowdown later this year.

Delaying elective procedures can have serious medical consequences, as when a detectable polyp develops into a tumor because a patient skips a colonoscopy. Some hospitals said their emergency rooms were already seeing patients with dire conditions that could have been avoided had they not deferred surgery for economic reasons.

“We’re probably seeing five or six of those a day at each of our hospitals,” said Zeff Ross, a senior vice president at Memorial Healthcare System, which operates six hospitals in South Florida. “Someone gets an attack of diverticulitis, but they wait. They get it a second time and the doctor tells them to get the surgery done now, but they still wait. The third time, it perforates and that’s a much tougher surgery, much more dangerous for the patient and with a longer length of stay.”

The slowdown is likely to have significant financial repercussions. Elective operations are typically covered by private insurance plans that tend to reimburse hospitals and doctors at higher rates than government insurance programs like Medicare and Medicaid. As those payments dwindle, so do hospital profit margins and the resources to provide charity care to a growing number of uninsured.

“Elective admissions could represent only 9 or 10 percent of a hospital’s admissions and yet represent 25 percent of its bottom line,” said Michael A. Sachs, chief executive of Sg2, a health care consulting firm. “They’re the patients that subsidize the underfunding associated with Medicaid and Medicare patients and uncompensated care.”

The loss of revenue and growth in uncompensated care is conspiring with other byproducts of the recession — declining philanthropy, battered investments and tight credit — to force many hospitals to lay off workers, postpone expansions and cancel equipment purchases.

A study released in November by the American Hospital Association found that about one-third of hospitals had seen either a moderate or significant decrease in elective procedures in the previous three months. More recent studies in states like New Jersey and Georgia have put the figure closer to 50 percent. Ambulatory surgical centers, which had experienced exponential growth over the last decade, are also reporting a slowdown in some markets.

Dr. David S. George, an Ohio ophthalmologist who with two other physicians owns an outpatient eye center, said they performed 5 percent fewer cataract operations in 2008 than in 2007, following nearly a decade of consistent 10 percent annual growth.

“That was the first down year we’ve had,” Dr. George said. “When we tell patients about the benefits of cataract surgery, we’re getting more answers like, ‘Well, it’s not that bad yet. Let’s check it out in six months or a year.’ Even those with good insurance are very concerned about the co-pay and the out-of-pocket costs.”

That is the case for Jane Bagwell, a 60-year-old legal secretary in Atlanta, who has chosen to delay surgery to repair a torn rotator cuff in her left shoulder, even though she rates her pain as an 8 on a scale of 1 to 10.

In a less terrifying economy, Ms. Bagwell said, she would not hesitate to schedule the operation. These days, however, she finds herself pinching every penny, including the ones that would help her pay the 20 percent share of surgical costs not covered by insurance. And given that her law firm is laying off staff members, she worries that if she took three weeks off to recuperate, her job might be eliminated before she could return.

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The trends are far from universal, with some physicians and hospitals saying they have seen little change. Several doctors interviewed reported that some of their patients were deferring procedures while others were accelerating them.

“They’re trying to get things done next week because they know they’re going to be losing their insurance or going to Cobra,” said Dr. Jeffrie L. Kamean, an Atlanta gastroenterologist.

Dr. Kamean was referring to the federal law that allows laid-off workers to continue their employer-sponsored insurance, though at costs that are often prohibitive (the federal stimulus package provides money to subsidize Cobra expenses).

Val Arnold, 37, a skin cancer survivor who lives in Holly, Mich., said she chose to have reconstructive surgery on her nose on Feb. 13 because she had been laid off from her job with General Motors and would lose her employer-sponsored insurance on March 1. She would have preferred to wait, so that she would be immediately available if the automaker reactivated her job.

“It was like all of a sudden I have to get it done now,” Ms. Arnold said during her two-week recuperation. “What if they call me this week?”

Health experts predict that as the economy worsens, more insured people will begin deferring care because they cannot afford the high deductibles common in the insurance market.

“During good economic times, the trade-offs aren’t as severe,” said David Dranove, a professor of health-industry management at Northwestern University. “It’s that $2,000 for elective surgery versus that vacation in Cancún. Now it’s $2,000 for the surgery versus making the mortgage payments, and suddenly the surgery can wait.”

At Beaumont Hospital in Royal Oak, Mich., outpatient surgical volumes are down 10 percent so far this year compared with 2008. At Elkhart General Hospital in Elkhart, Ind., the 498 operations in January were 28 fewer than in January 2008 and 63 fewer than projected in this year’s budget, said Gregory W. Lintjer, the president.

“We’re seeing a slowdown in hip and knee replacements, the kind of things that people can live with a little longer if they so choose,” Mr. Lintjer said.

Not surprisingly, the steepest drop has been in plastic surgery, which is typically not covered by insurance. Dr. John W. Canady, the president of the American Society of Plastic Surgeons, said business seemed to be off by an average of 30 percent among his members, particularly for surgical procedures.

On the other hand, Dr. Canady said, plastic surgeons are starting to field requests for Botox and other minor aesthetic improvements from middle-aged patients who find themselves competing for jobs against younger applicants.

Correction: March 18, 2009

An article on Saturday about the recession’s effect on patients’ decisions to defer or speed up elective surgery misidentified the site of a Caterpillar plant that has had huge layoffs. It is in Peoria, Ill., not Elkhart, Ind.

A version of this article appears in print on , on Page A1 of the New York edition with the headline: Bad Economy Leads Patients To Put Off Surgery, or Rush It. Order Reprints|Today's Paper|Subscribe